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2013
JOURNAL OF CLINICAL ONCOLOGY
Gary H. Lyman, Nicole M. Kuderer, and
Jeffrey M. Clarke, Duke University and
Duke Cancer Institute, Durham; Nigel S.
Key, Lineberger Comprehensive Cancer
Center, University of North Carolina, Chapel
Hill, NC; Alok A. Khorana, Taussig Cancer
Institute, Cleveland Clinic, Cleveland, OH;
Agnes Y. Lee, University of British Columbia, Vancouver, British Columbia; Mark N.
Levine, McMaster University, Hamilton,
Ontario, Canada; Juan Ignacio Arcelus,
Hospital Universitario Virgen de las Nieves,
University of Granada, Granada, Spain;
Edward P. Balaban, University of Pittsburgh
Cancer Centers Network, Pittsburgh, PA;
Christopher R. Flowers, Emory University
School of Medicine and Winship Cancer
Institute, Atlanta, GA; Charles W. Francis,
James P. Wilmot Cancer Center and
University of Rochester, Rochester, NY;
Leigh E. Gates, patient representative,
Denver, CO; Ajay K. Kakkar, Thrombosis
Research Institute, London, United Kingdom; Howard A. Liebman, Keck School of
Medicine, University of Southern California,
Los Angeles; Margaret A. Tempero,
University of California–San Francisco
Pancreas Center, San Francisco, CA;
Sandra L. Wong, University of Michigan,
Ann Arbor, MI; Ann Alexis Prestrud, American Society of Clinical Oncology, Alexandria, VA; and Anna Falanga, Hospital Papa
Giovanni XXIII, Bergamo, Italy.
Published online ahead of print at
www.jco.org on May 13, 2013.
Clinical Practice Guidelines Committee
Approval: Pending
Editor’s note: This American Society of
Clinical Oncology Clinical Practice Guideline
Update provides recommendations with
comprehensive discussion of the relevant
literature for each recommendation. The
Data Supplement, including evidence
tables, is available at http://www.asco.org/
guidelines/vte.
Authors’ disclosures of potential conflicts
of interest and author contributions are
found at the end of this article.
Corresponding author: American Society of
Clinical Oncology, 2318 Mill Rd, Suite 800,
Alexandria, VA 22314; e-mail:
[email protected].
© 2013 by American Society of Clinical
Oncology
A S C O
S P E C I A L
A R T I C L E
Venous Thromboembolism Prophylaxis and Treatment in
Patients With Cancer: American Society of Clinical
Oncology Clinical Practice Guideline Update
Gary H. Lyman, Alok A. Khorana, Nicole M. Kuderer, Agnes Y. Lee, Juan Ignacio Arcelus, Edward P. Balaban,
Jeffrey M. Clarke, Christopher R. Flowers, Charles W. Francis, Leigh E. Gates, Ajay K. Kakkar, Nigel S. Key, Mark N. Levine,
Howard A. Liebman, Margaret A. Tempero, Sandra L. Wong, Ann Alexis Prestrud, and Anna Falanga
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Purpose
To provide recommendations about prophylaxis and treatment of venous thromboembolism (VTE)
in patients with cancer. Prophylaxis in the outpatient, inpatient, and perioperative settings was
considered, as were treatment and use of anticoagulation as a cancer-directed therapy.
Methods
A systematic review of the literature published from December 2007 to December 2012 was
completed in MEDLINE and the Cochrane Collaboration Library. An Update Committee reviewed
evidence to determine which recommendations required revision.
Results
Forty-two publications met eligibility criteria, including 16 systematic reviews and 24 randomized
controlled trials.
Recommendations
Most hospitalized patients with cancer require thromboprophylaxis throughout hospitalization. Thromboprophylaxis is not routinely recommended for outpatients with cancer. It may be considered for selected
high-risk patients. Patients with multiple myeloma receiving antiangiogenesis agents with chemotherapy
and/or dexamethasone should receive prophylaxis with either low–molecular weight heparin (LMWH) or
low-dose aspirin. Patients undergoing major cancer surgery should receive prophylaxis, starting before
surgery and continuing for at least 7 to 10 days. Extending prophylaxis up to 4 weeks should be considered
in those with high-risk features. LMWH is recommended for the initial 5 to 10 days of treatment for deep
vein thrombosis and pulmonary embolism as well as for long-term (6 months) secondary prophylaxis. Use
of novel oral anticoagulants is not currently recommended for patients with malignancy and VTE.
Anticoagulation should not be used for cancer treatment in the absence of other indications. Patients with
cancer should be periodically assessed for VTE risk. Oncology professionals should provide patient
education about the signs and symptoms of VTE.
J Clin Oncol 31:2189-2204. © 2013 by American Society of Clinical Oncology
INTRODUCTION
The American Society of Clinical Oncology (ASCO)
first published an evidence-based clinical practice
guideline on prophylaxis and treatment of venous
thromboembolism (VTE) in 2007.1 ASCO guidelines are updated at intervals determined by an Update Committee; this is a full guideline update. Table
1 provides a summary of the 2007 and 2012 guideline recommendations.
GUIDELINE QUESTIONS
2. Should ambulatory patients with cancer receive anticoagulation for VTE prophylaxis
during systemic chemotherapy?
3. Should patients with cancer undergoing surgery receive perioperative VTE prophylaxis?
4. What is the best method for treatment of patients with cancer with established VTE to prevent recurrence?
5. Should patients with cancer receive anticoagulants in the absence of established VTE to improve survival?
6. What is known about risk prediction and
awareness of VTE among patients with cancer?
METHODS
0732-183X/13/3117w-2189w/$20.00
DOI: 10.1200/JCO.2013.49.1118
1. Should hospitalized patients with cancer receive anticoagulation for VTE prophylaxis?
Panel Composition
An Update Committee was formed (Appendix Table
A1, online only) to review data published since the initial
© 2013 by American Society of Clinical Oncology
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Lyman et al
guideline and update recommendations, as warranted, considering evidence
identified by the systematic review.
Guideline Development Process
The Update Committee met in July 2012 and had a second meeting via
teleconference. During those meetings, the Update Committee reviewed evidence identified by the systematic review and revised guideline recommendations. Additional work on the guideline was completed electronically. The
steering committee and lead ASCO staff person prepared an updated guideline
to share with the Update Committee members for review. As per standard
practice, the guideline was submitted to Journal of Clinical Oncology for review.
The VTE Update Committee and the ASCO Clinical Practice Guideline Committee reviewed and approved this guideline document before publication.
Guideline Policy
The practice guideline is not intended to substitute for the independent
professional judgment of the treating physician. Practice guidelines do not
account for individual variation among patients and may not reflect the most
recent evidence. This guideline does not recommend any particular product or
course of medical treatment. Use of the practice guideline is voluntary. The
Additional information is available at http://www.asco.org/guidelines/vte.
ASCO believes that cancer clinical trials are vital to inform medical
decisions and improve cancer care and that all patients should have the opportunity to participate.
Update Methodology
The goal of this update was to review evidence available since publication
of the original guideline and to revise recommendations, as needed, about the
prevention and treatment of VTE among patients with cancer. One new
clinical question, regarding risk, was added, and a separate systematic review
was completed to address this issue.
Literature Review and Analysis
Literature search strategy. The effectiveness search included the MEDLINE, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials databases. Conference proceedings from annual
meetings of ASCO, the American Society of Hematology, the European Society of Medical Oncology, and the International Society of Thrombosis and
Hemostasis were searched through 2012 or the most recent year available. The
risk assessment search was completed in MEDLINE.
Reference lists from seminal articles, guidelines from other organizations, and recent review articles were hand searched for additional citations.
THE BOTTOM LINE
ASCO GUIDELINE
Venous Thromboembolism Prophylaxis and Treatment in Patients With Cancer
Interventions
● Pharmacologic anticoagulation
Target Audience
● Medical oncologists, surgical oncologists, hospitalists, oncology nurses
Key Recommendations
● Most hospitalized patients with cancer require thromboprophylaxis throughout hospitalization
● Thromboprophylaxis is not routinely recommended for ambulatory patients with cancer; it may be considered for very select
high-risk patients
● Patients with multiple myeloma receiving antiangiogenesis agents with chemotherapy and/or dexamethasone should receive prophylaxis with either low molecular–weight heparin (LMWH) or low-dose aspirin to prevent venous thromboembolism (VTE)
● Patients undergoing major cancer surgery should receive prophylaxis starting before surgery and continuing for at least 7 to 10
days
● Extending postoperative prophylaxis up to 4 weeks should be considered in those with high-risk features
● LMWH is recommended for the initial 5 to 10 days of treatment for patients with established deep vein thrombosis and pulmonary embolism, as well as for long-term (6 months) secondary prophylaxis
● Use of novel oral anticoagulants is not currently recommended for patients with malignancy and VTE
● Anticoagulation should not be used to extend survival in patients with cancer in the absence of other indications
● Patients with cancer should be periodically assessed for VTE risk
● Oncology professionals should provide patient education about the signs and symptoms of VTE
Methods
● An Expert Panel was convened to develop clinical practice guideline recommendations based on a review of evidence provided by
a systematic review of the medical literature
Additional Information
This guideline was published in Journal of Clinical Oncology. The Data Supplement, including evidence tables, and clinical tools and
resources, can be found at www.asco.org/guidelines/vte.
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© 2013 by American Society of Clinical Oncology
JOURNAL OF CLINICAL ONCOLOGY
VTE Prophylaxis and Treatment: ASCO Guideline Update
Table 1. VTE Prophylaxis and Treatment Recommendations
Strength of Evidence Type and
Strength of Recommendation
2013 Recommendation
Inpatients
1.1 Hospitalized patients who have active malignancy with
acute medical illness or reduced mobility should receive
pharmacologic thromboprophylaxis in the absence of
bleeding or other contraindications.
1.2 Hospitalized patients who have active malignancy without
additional risk factors may be considered for pharmacologic
thromboprophylaxis in the absence of bleeding or other
contraindications.
1.3 Data are inadequate to support routine thromboprophylaxis
in patients admitted for minor procedures or short
chemotherapy infusion or in patients undergoing stem-cell/
bone marrow transplantation.
Outpatients
2.1 Routine pharmacologic thromboprophylaxis is not
recommended in cancer outpatients.
Evidence: strong
Recommendation type, strength:
evidence based, strong
3.2 Prophylaxis should be commenced preoperatively.
3.3 Mechanical methods may be added to pharmacologic
thromboprophylaxis but should not be used as monotherapy
for VTE prevention unless pharmacologic methods are
contraindicated because of active bleeding or high bleeding
risk.
3.4 A combined regimen of pharmacologic and mechanical
prophylaxis may improve efficacy, especially in the highestrisk patients.
3.5 Pharmacologic thromboprophylaxis for patients undergoing
major surgery for cancer should be continued for at least 7
to 10 days. Extended prophylaxis with LMWH for up to 4
weeks postoperatively should be considered for patients
undergoing major abdominal or pelvic surgery for cancer
who have high-risk features such as restricted mobility,
obesity, history of VTE, or with additional risk factors as
listed in Table 3. In lower-risk surgical settings, the decision
on appropriate duration of thromboprophylaxis should be
made on a case-by-case basis considering the individual
patient.
Hospitalized patients with cancer should be considered
candidates for VTE prophylaxis with anticoagulants in
the absence of bleeding or other contraindications to
anticoagulation.
Evidence: moderate
Recommendation type, strength:
evidence based, strong
Evidence: insufficient
Recommendation type, strength:
informal consensus, moderate
Evidence: moderate
Recommendation type, strength:
evidence based, strong
2.2 Based on limited RCT data, clinicians may consider LMWH Evidence: moderate
prophylaxis on a case-by-case basis in highly selected
Recommendation type, strength:
outpatients with solid tumors receiving chemotherapy.
evidence based, weak
Consideration of such therapy should be accompanied by a
discussion with the patient about the uncertainty concerning
benefits and harms as well as dose and duration of
prophylaxis in this setting.
2.3 Patients with multiple myeloma receiving thalidomide- or
Evidence: moderate
lenalidomide-based regimens with chemotherapy and/or
Recommendation type, strength:
dexamethasone should receive pharmacologic
evidence based, strong
thromboprophylaxis with either aspirin or LMWH for lowerrisk patients and LMWH for higher-risk patients.
Perioperative
3.1 All patients with malignant disease undergoing major
surgical intervention should be considered for
pharmacologic thromboprophylaxis with either UFH or
LMWH unless contraindicated because of active bleeding or
high bleeding risk.
2007 Recommendation
Evidence: strong
Recommendation type, strength:
evidence-based, strong
Evidence: moderate
Recommendation type, strength:
evidence based, moderate
Evidence: moderate
Recommendation type, strength:
evidence based, strong
Evidence: moderate
Recommendation type, strength:
informal consensus, moderate
Evidence: strong
Recommendation type, strength:
evidence based, strong to
moderate
Routine prophylaxis with an antithrombotic agent is not
recommended.
Patients receiving thalidomide or lenalidomide with
chemotherapy or dexamethasone are at high risk for
thrombosis and warrant prophylaxis. Until such time
as data are available from RCTs, LMWH or adjusteddose warfarin (INR approximately 1.5) is
recommended in patients with myeloma receiving
thalidomide plus chemotherapy or dexamethasone.
This recommendation is based on extrapolation from
studies of postoperative prophylaxis in orthopedic
surgery and a trial of adjusted-dose warfarin in breast
cancer. RCTs evaluating antithrombotic agents are
needed in patients with multiple myeloma receiving
thalidomide or lenalidomide plus chemotherapy and/or
dexamethasone. Research identifying better markers
of ambulatory patients with cancer most likely to
develop VTE is urgently needed.
All patients undergoing major surgical intervention for
malignant disease should be considered for
thromboprophylaxis. Patients undergoing laparotomy,
laparoscopy, or thoracotomy lasting greater than 30
minutes should receive pharmacologic
thromboprophylaxis with either low-dose UFH or
LMWH unless contraindicated because of high risk of
bleeding or active bleeding.
Prophylaxis should be commenced preoperatively or as
early as possible in the postoperative period.
Mechanical methods may be added to pharmacologic
methods but should not be used as monotherapy for
VTE prevention unless pharmacologic methods are
contraindicated because of active bleeding.
A combined regimen of pharmacologic and mechanical
prophylaxis may improve efficacy, especially in the
highest-risk patients.
Prophylaxis should be continued for at least 7 to 10 days
postoperatively. Prolonged prophylaxis for up to 4
weeks may be considered in patients undergoing
major abdominal or pelvic surgery for cancer with
high-risk features such as residual malignant disease
after operation, obese patients, and those with a
history of VTE.
(continued on following page)
www.jco.org
© 2013 by American Society of Clinical Oncology
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Lyman et al
Table 1. VTE Prophylaxis and Treatment Recommendations (continued)
2013 Recommendation
Treatment and secondary prophylaxis
4.1 LMWH is preferred over UFH for the initial 5 to 10 days of
anticoagulation for the patient with cancer with newly
diagnosed VTE who does not have severe renal impairment
(defined as creatinine clearance ⬍ 30 mL/min).
4.2 For long-term anticoagulation, LMWH for at least 6
months is preferred because of improved efficacy over
VKAs. VKAs are an acceptable alternative for long-term
therapy if LMWH is not available.
4.3 Anticoagulation with LMWH or VKA beyond the initial 6
months may be considered for select patients with active
cancer, such as those with metastatic disease or those
receiving chemotherapy.
4.4 The insertion of a vena cava filter is only indicated for
patients with contraindications to anticoagulant therapy (see
Table 4). It may be considered as an adjunct to
anticoagulation in patients with progression of thrombosis
(recurrent VTE or extension of existing thrombus) despite
optimal therapy with LMWH.
4.5 For patients with primary CNS malignancies,
anticoagulation is recommended for established VTE as
described for other patients with cancer. Careful monitoring
is necessary to limit the risk of hemorrhagic complications.
4.6 Use of novel oral anticoagulants for either prevention or
treatment of VTE in patients with cancer is not
recommended at this time.
4.7 Based on consensus, incidental PE and DVT should be
treated in the same manner as symptomatic VTE.
Treatment of splanchnic or visceral vein thrombi diagnosed
incidentally should be considered on a case-by-case basis,
considering potential benefits and risks of anticoagulation.
Anticoagulation and survival
5.1 Anticoagulants are not recommended to improve survival
in patients with cancer without VTE.
5.2 Patients with cancer should be encouraged to participate
in clinical trials designed to evaluate anticoagulant therapy
as an adjunct to standard anticancer therapies.
Risk assessment
6.1 Based on consensus, the Panel recommends that patients
with cancer be assessed for VTE risk at the time of
chemotherapy initiation and periodically thereafter. Individual
risk factors, including biomarkers or cancer site, do not
reliably identify patients with cancer at high risk of VTE. In
the outpatient setting, risk assessment can be conducted
based on a validated risk assessment tool (Table 5).
6.2 Based on consensus, the Panel recommends that
oncologists educate patients regarding VTE, particularly in
settings that increase risk such as major surgery,
hospitalization, and while receiving systemic antineoplastic
therapy.
Strength of Evidence Type and
Strength of Recommendation
2007 Recommendation
Evidence: strong
Recommendation type, strength:
evidence based, strong
LMWH is the preferred approach for the initial 5 to 10
days of anticoagulant treatment of the patient with
cancer with established VTE.
Evidence: strong
Recommendation type, strength:
evidence based, strong
LMWH given for at least 6 months is also the preferred
approach for long-term anticoagulant therapy. VKAs
with a targeted INR of 2 to 3 are acceptable for longterm therapy when LMWH is not available.
After 6 months, indefinite anticoagulant therapy should
be considered for selected patients with active
cancer, such as those with metastatic disease and
those receiving chemotherapy. This recommendation
is based on Panel consensus in the absence of clinical
trials data.
The insertion of a vena cava filter is only indicated for
patients with contraindications to anticoagulant
therapy and in those with recurrent VTE despite
adequate long-term therapy with LMWH.
Evidence: insufficient
Recommendation type, strength:
informal consensus, weak to
moderate
Evidence: weak to moderate
Recommendation type, strength:
informal consensus, moderate
Evidence: moderate
Recommendation type, strength:
informal consensus, strong
For patients with CNS malignancies, anticoagulation is
recommended for established VTE as described for
other patients with cancer. Careful monitoring is
necessary to limit the risk of hemorrhagic
complications. Anticoagulation should be avoided in
the presence of active intracranial bleeding, recent
surgery, preexisting bleeding diathesis such as
thrombocytopenia (platelet count ⬍ 50,000/␮L), or
coagulopathy.
Evidence: insufficient
Recommendation type, strength:
informal consensus, strong
Evidence: insufficient
Recommendation type, strength:
informal consensus, moderate
Evidence: weak to moderate
Recommendation type, strength:
informal consensus, moderate
Anticoagulants are not recommended to improve survival
in patients with cancer without VTE. Patients with
cancer should be encouraged to participate in clinical
trials designed to evaluate anticoagulant therapy as an
adjunct to standard anticancer therapies.
Evidence: moderate
Recommendation type, strength:
informal consensus, strong
New for 2012 Update
Evidence: insufficient
Recommendation type, strength:
informal consensus, strong
Abbreviations: INR, international normalized ratio; LMWH, low–molecular weight heparin; PE, pulmonary embolism; RCT, randomized controlled trial; UFH,
unfractionated heparin; VKA, vitamin K antagonist; VTE, venous thromboembolism.
The Update Committee reviewed the list of included reports for completeness.
Subject headings and keywords used in the efficacy literature search included
four major categories: VTE, anticoagulation, malignancy, and randomized
controlled trials (RCTs). The full search string is available in the Data Supplement. The risk literature search also included four major categories: risk
assessment, VTE, cancer, and cohort studies.
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© 2013 by American Society of Clinical Oncology
Inclusion and exclusion criteria. Articles for the efficacy systematic
review were selected for inclusion if they were RCTs or systematic reviews
of RCTs that assessed the efficacy and safety of anticoagulation in
patients with cancer and included at least 50 patients per arm. Only data
from conference proceedings available as full presentations or posters
were included.
JOURNAL OF CLINICAL ONCOLOGY
VTE Prophylaxis and Treatment: ASCO Guideline Update
For the risk systematic review, studies from the ambulatory setting that
either developed or validated risk models were included. Only reports that
included multivariate analyses were eligible. Risk assessment models limited to
single cancer types were excluded.
Data extraction. Eligible reports for both reviews were preliminarily
identified after the literature search. Full-text copies were obtained to further
assess eligibility. Articles that met eligibility for the efficacy search underwent
data extraction by ASCO staff for study design and quality, patient characteristics, outcomes, and adverse events. Outcomes of interest included symptomatic and asymptomatic thrombotic events found on screening, major and
minor bleeding, early and overall mortality, sudden death, and adverse events.
For the risk review, data extraction included study characteristics, quality, and
risk assessment model development and evaluation. Outcomes of interest
included factors incorporated into the risk assessment model, model equation,
and outcomes according to risk.
Evidence summary tables (Data Supplement) were reviewed for accuracy and completeness by an ASCO staff member who was not involved in data
extraction. Disagreements were resolved through discussion; the Steering
Committee was consulted if necessary.
Study quality. Trial characteristics from the RCTs were extracted to
evaluate the potential for bias. Study quality was also assessed for the reports in
the risk systematic review.
Guideline and Conflicts of Interest
The Update Committee was assembled in accordance with ASCO’s Conflict of Interest Management Procedures for Clinical Practice Guidelines
(“Procedures,” summarized at http://www.asco.org/guidelinescoi). Members
of the Update Committee completed ASCO’s disclosure form, which requires
disclosure of financial and other interests that are relevant to the subject matter
of the guideline, including relationships with commercial entities that are
reasonably likely to experience direct regulatory or commercial impact as the
result of promulgation of the guideline. Categories for disclosure include
employment relationships, consulting arrangements, stock ownership, honoraria, research funding, and expert testimony. In accordance with the Procedures, the majority of the members of the Update Committee did not disclose
any such relationships.
Revision Dates
At intervals, the Update Committee co-chairs and two Update Committee members designated by the co-chairs will determine the need for guideline
revisions based on the available literature. If necessary, the Update Committee
will be reconvened. When appropriate, the Update Committee will suggest
revised recommendations to the Clinical Practice Guideline Committee.
RESULTS
Literature Search
The efficacy literature search yielded a total of 380 citations
from MEDLINE, 531 citations from conference proceedings, and
18 from hand searching. Forty-two reports provisionally met inclusion and exclusion criteria and were selected for full-text review.
Of those, reports from 30 trials and systematic reviews were selected for data extraction. The QUOROM diagram is available in
the Data Supplement.
For the risk systematic review, the MEDLINE literature search
yielded 664 citations. Of those, 54 provisionally met eligibility criteria
and were selected for full-text review. Six articles were identified for
data extraction.
Study Quality and Limitations of the Literature
Publications identified by the systematic review varied with respect to potential for bias, ranging from low to high. A majority of the
trials were of moderate quality. Specific quality issues are discussed
within the section for the relevant clinical question.
www.jco.org
GUIDELINE RECOMMENDATIONS: CLINICAL QUESTION 1
Should hospitalized patients with cancer receive anticoagulation for
VTE prophylaxis?
Recommendation 1.1
Hospitalized patients who have active malignancy with
acute medical illness or reduced mobility should receive pharmacologic thromboprophylaxis in the absence of bleeding or
other contraindications.
Recommendation 1.2
Hospitalized patients who have active malignancy without additional risk factors may be considered for pharmacologic thromboprophylaxis in the absence of bleeding or other contraindications.
Recommendation 1.3
Data are inadequate to support or oppose thromboprophylaxis in patients admitted for minor procedures or short chemotherapy infusion or in patients undergoing stem-cell/bone
marrow transplantation.
Literature Update and Analysis 1
Three randomized trials were identified by the systematic review:
CERTIFY (Certoparin for Thromboprophylaxis in Medical Patients),
CERTAIN (Certoparin Versus Unfractionated Heparin for the Prevention of Thromboembolic Complications in Acutely Ill Medical
Patients), and EXCLAIM (Extended Prophylaxis for Venous ThromboEmbolism in Acutely Ill Medical Patients with Prolonged
Immobilization).2-4 EXCLAIM evaluated extended prophylaxis.2 One
systematic review and meta-analysis of inpatient thromboprophylaxis
was also identified.5 Dosing information is provided in Table 2.
Primary Prophylaxis
Both new primary prophylaxis trials in medically ill patients,
CERTAIN and CERTIFY, compared a low molecular–weight heparin
(LMWH), certoparin, with unfractionated heparin (UFH). The
primary outcome for both trials was the composite of symptomatic
or asymptomatic deep vein thrombosis (DVT), symptomatic pulmonary embolism (PE), or VTE-related death. Among the 172
patients randomly assigned in the CERTAIN trial, 8.0% and 9.2%
in the UFH and LMWH groups, respectively, had active or previous cancer (not significant).3 The primary end point was reported
in 18% of patients receiving UFH and 10.7% of patients receiving
certoparin (not significant).
Patients with cancer were eligible to participate in CERTIFY, but
the percentage was not reported.4 Among the 3,244 patients randomly
assigned in this trial, the primary outcome of DVT or PE occurred in
3.9% in the certoparin arm compared with 4.5% receiving UFH (not
significant). Both trials included an older patient population; the
mean age in CERTIFY was ⬎ 78 years,4 and in CERTAIN, it was ⬎ 70
years.3 Neither trial reported data for cancer subgroups. Bleeding rates
were higher with UFH compared with LMWH. Sudden death was not
reported for either trial.
The systematic review examined pharmacologic thromboprophylaxis with LMWH, UFH, fondaparinux, and placebo.5 DVT rates
were lower with LMWH/fondaparinux compared with placebo (odds
© 2013 by American Society of Clinical Oncology
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Table 2. Dosing Regimens for Prophylaxis/Treatment of VTE in Patients With Cancer
Regimena
Drug
Pharmacologic (anticoagulant) prophylaxis
Hospitalized medical patientsb
Unfractionated heparin
Dalteparin
Enoxaparin
Fondaparinuxd
Surgical patientsbe
Unfractionated heparin
Dalteparin
Enoxaparin
Fondaparinuxd
Treatment of established VTEf
Initial
Unfractionated heparing
Dalteparingij
Enoxaparingijk
Tinzaparingijl
Fondaparinuxgi
Long termm
Dalteparinjin
Enoxaparinijk
Tinzaparinjl
Warfarin
5,000 U once every 8 hoursc
5,000 U once daily
40 mg once daily
2.5 mg once daily
5,000 U 2-4 hours preoperatively and once every 8 hoursc thereafter or 5,000 U 10-12 hours preoperatively and
5,000 U once daily thereafter
2,500 U 2-4 hours preoperatively and 5,000 U once daily thereafter or 5,000 U 10-12 hours preoperatively and
5,000 U once daily thereafter
20 mg 2-4 hours preoperatively and 40 mg once daily thereafter or 40 mg 10-12 hours preoperatively and 40
mg once daily thereafter
2.5 mg qd beginning 6-8 h postoperatively
80 U/kg IV bolus, then 18 U/kg per hour IV; adjust dose based on aPTTh
100 U/kg once every 12 hours; 200 U/kg once daily
1 mg/kg once every 12 hours; 1.5 mg/kg once daily
175 U/kg once per day
⬍ 50 kg, 5.0 mg once daily; 50-100 kg, 7.5 mg once daily; ⬎ 100 kg, 10 mg once daily
200 U/kg once daily for 1 month, then 150 U/kg once daily
1.5 mg/kg once daily; 1 mg/kg once every 12 hours
175 U/kg once daily
Adjust dose to maintain INR 2 to 3
Abbreviations: aPTT, activated partial thromboplastin time; FDA, US Food and Drug Administration; INR, international normalized ratio; IV, intravenous; LMWH,
low–molecular weight heparin; VTE, venous thromboembolism.
a
All doses are administered as subcutaneous injections except as indicated.
b
Duration for medical patients is length of hospital stay or until fully ambulatory; for surgical patients, prophylaxis should be continued for at least 7 to 10 days.
Extended prophylaxis for up to 4 weeks should be considered for high-risk patients.
c
Unfractionated heparin 5,000 U every 12 hours has also been used but appears to be less effective.
d
This drug is not approved by the FDA for this indication.
e
When neuraxial anesthesia or analgesia is planned, prophylactic doses of once-daily LMWH should not be administered within 10 to 12 hours before the
procedure/instrumentation (including epidural catheter removal). After the surgery, the first dose of LMWH can be administered 6 to 8 hours postoperatively. After
catheter removal, the first dose of LMWH can be administered no earlier than 2 hours afterward. Clinicians should refer to their institutional guidelines and the
American Society of Regional Anesthesia Guidelines for more information.6
f
Contraindications to therapeutic anticoagulation are listed in Table 4.
g
Parenteral anticoagulants should overlap with warfarin for 5 to 7 days minimum and continued until INR is in the therapeutic range for 2 consecutive days.
h
Unfractionated heparin infusion rate should be adjusted to maintain the aPTT within the therapeutic range in accordance with local protocol to correspond with
a heparin level of 0.3 to 0.7 U/mL using a chromogenic Xa assay.
i
Dependent on significant renal clearance; avoid in patients with creatinine clearance ⱕ 30 mL/minute or adjust dose based on anti–factor Xa levels.
j
Optimal dose unclear in patients ⬎ 120 kg.
k
Twice-daily dosing may be more efficacious than once-daily dosing for enoxaparin based on post hoc data.
l
This drug is not available in the United States.
m
Total duration of therapy depends on clinical circumstances. See Clinical Question 4, section entitled “Initial and Long-Term Treatment Up to 6 Months,” for more
detailed discussion.
n
This is the only LMWH with FDA approval for extended therapy to prevent recurrent thrombosis in patients with cancer.
ratio [OR], 0.60; 95% CI, 0.47 to 0.75) but similar between LMWH
and UFH (OR, 0.92; 95% CI, 0.56 to 1.52). No differences in the rate of
death or PE were noted between patients who were treated with
LMWH/fondaparinux, UFH, or placebo. Major bleeding rates were
similar across all treatment arms considered. Minor bleeding rates
were similar with LMWH and UFH and greater than in placebotreated patients. Cancer-specific rates were not provided for either
VTE or bleeding.
Extended Prophylaxis
In an RCT, 6,085 acutely ill medical patients were assigned to
extended prophylaxis with enoxaparin or placebo for 28 days (⫾ 4
days) after receiving open-label enoxaparin for an initial 10 days (⫾ 4
days).2 Of the patients in the LMWH arm, 14.1% had cancer, as did
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16.0% in the placebo arm. The primary outcomes were VTE defined as
a composite of symptomatic or asymptomatic proximal DVT, symptomatic PE, and fatal PE, and major bleeding. The proportion of VTE
events was greater with placebo: 4.0% versus 2.5% for an absolute risk
difference of ⫺1.53% (95% CI, ⫺2.54% to ⫺0.52%). Major bleeding
was uncommon but significantly greater with active therapy: 0.8%
versus 0.3%. The early mortality rate was similar across trial arms
(hazard ratio [HR], 0.93; 95% CI, 0.65 to 1.32).2 Cancer-specific data
were not reported.
Trial Considerations
The inpatient trials enrolled mixed populations including patients with cancer as well as general medical patients. To date, no trials
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Table 3. Risk Factors and Biomarkers for Cancer-Associated Thrombosis
Cancer Related
Treatment Related
Primary site
Stage (higher for advanced stage)
Chemotherapy
Antiangiogenic agents (eg,
thalidomide, lenalidomide)
Cancer histology (higher for
adenocarcinoma than
squamous cell)
Hormonal therapy
Time after initial diagnosis (highest
in first 3 to 6 months)
Erythropoiesis-stimulating agents
Transfusions
Indwelling venous access devices
Radiation therapy
Surgery ⬎ 60 min
Patient Related
Biomarkers
Older age
Race (higher in African Americans;
lower in Asians/Pacific
Islanders)
Medical comorbidities (infection,
renal disease, pulmonary
disease, arterial
thromboembolism)
Obesity
History of VTE
Diminished performance status
Inherited prothrombotic mutations
Platelet count (ⱖ 350,000/␮L)
Leukocyte count (⬎ 11,000/␮L)
Hemoglobin (⬍ 10 g/dL)
Abbreviation: VTE, venous thromboembolism.
have evaluated inpatient thromboprophylaxis in a cancer-only population. These recommendations were formulated by extrapolating the
best available data. All RCTs included reduced mobility as an eligibility
criterion, but the definitions of immobility were not explicit or consistent. This limits generalizability of these data to all hospitalized
patients with cancer and tempered the willingness of the Update
Committee to recommend thromboprophylaxis for all inpatients
with malignancy.
The extended thromboprophylaxis trial, CERTAIN, indicates
that prolonging anticoagulation reduces VTE event rates but increases
the risk of bleeding. Importantly, a midstudy amendment narrowed
the eligible patient population after interim analysis noted limited
efficacy in patients without reduced mobility.2 Findings from this trial
must be interpreted with this narrow patient population in mind.
Risk Among Inpatients
A vast majority of hospitalized patients with cancer are at
moderate to high risk for thromboembolic events, because active
cancer is a strong risk factor.7-13 Most patients have additional risk
factors, including comorbid conditions such as infection, immobility, or advanced age.14 The benefit of prophylaxis increases with
the risk of VTE. Table 3 includes a list of risk factors that can be
used to evaluate risk in oncology inpatients. Risk is further addressed in Clinical Question 6.
CLINICAL QUESTION 2
Should ambulatory patients with cancer receive anticoagulation for
VTE prophylaxis during systemic chemotherapy?
Recommendation 2.1
Routine pharmacologic thromboprophylaxis is not recommended in cancer outpatients.
Recommendation 2.2
Based on limited RCT data, clinicians may consider LMWH
prophylaxis on a case-by-case basis in highly selected outpatients with
solid tumors receiving chemotherapy. Consideration of such therapy
should be accompanied by a discussion with the patient about the
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uncertainty concerning benefits and harms as well as dose and duration of prophylaxis in this setting.
Recommendation 2.3
Patients with multiple myeloma receiving thalidomide- or
lenalidomide-based regimens with chemotherapy and/or dexamethasone should receive pharmacologic thromboprophylaxis with either
aspirin or LMWH for lower-risk patients and LMWH for higherrisk patients.
Literature Update and Analysis 2
The updated systematic review identified three systematic
reviews15-17 considering the ambulatory setting and nine RCTs.18-25
Two RCTs, SAVE-ONCO (Evaluation of AVE5026 in the Prevention
of Venous Thromboembolism in Cancer Patients Undergoing Chemotherapy),18 and PROTECHT (Prophylaxis of Thromboembolism
During Chemotherapy)19 included patients with a variety of solid
tumors. Two others, FRAGEM (Gemcitabine With or Without Dalteparin in Treating Patients With Locally Advanced or Metastatic Pancreatic Cancer)21 and PROSPECT-CONKO 004 (Chemotherapy
With or Without Enoxaparin in Pancreatic Cancer)24,25 included only
patients with pancreatic cancer. The PRODIGE (Dalteparin Low
Molecular Weight Heparin for Primary Prophylaxis of Venous
Thromboembolism in Brain Tumour Patients) trial examined anticoagulation for patients with glioma.23 Two recent trials evaluated
thromboprophylaxis in multiple myeloma.20,22 Final publications of
two trials discussed in the previous guideline are also discussed.26
Systematic Reviews
Two systematic reviews identified RCTs comparing LMWH prophylaxis in the outpatient setting with placebo or no prophylaxis.
Estimated risk ratios (RRs) across trials indicated decreases in symptomatic VTE events with LMWH thromboprophylaxis of 0.53 (95%
CI, 0.39 to 0.72) and 0.54 (95% CI, 0.31 to 0.95), respectively.16,17
Neither meta-analysis noted a statistically significant increase in bleeding with LMWH. Of note, the second report included only trials of
patients with advanced lung cancer from two RCTs.16 The relative risk
for symptomatic VTE was 0.58 (95% CI, 0.28 to 1.06).
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A recent Cochrane review compared the efficacy and safety of
LMWHs, vitamin K antagonists (VKAs), and direct thrombin inhibitors with no intervention or placebo in ambulatory patients with
cancer.15 Fewer symptomatic VTEs occurred with LMWH thromboprophylaxis in the pooled analysis of ⬎ 2,400 patients (RR, 0.62;
95% CI, 0.41 to 0.99). Rates of major and minor bleeding were not
consistently increased with anticoagulation compared with placebo.
Four trials specifically considered the LMWH dalteparin, allowing a
subgroup analysis of that agent. No difference in VTE event rates was
noted between dalteparin and placebo (RR, 0.75; 95% CI, 0.42
to 1.32).
The absolute differences in symptomatic VTE event rates between treated and control patients were ⬍ 5% in most trials. Among
the three systematic reviews, the absolute risk differences in VTE were
1.5%, 2.8%, and 1.7% with estimates of the number needed to treat
(NNT) of 67, 36, and 59, respectively, to prevent one symptomatic
VTE event across the included trials. Importantly, individual patient
data were not evaluated, limiting the assessment of patients with
different cancers, often receiving different cancer therapies and anticoagulants, and with varying degrees of VTE risk.
Recent Clinical Trials
Mixed solid tumors. The PROTECHT and SAVE-ONCO trials
evaluated thromboprophylaxis in ambulatory patients with cancer
receiving chemotherapy for locally advanced or metastatic solid tumors.18,19 These double-blind trials compared anticoagulation with
either the LMWH nadroparin or the ultra-LMWH semuloparin with
placebo. Semuloparin is not available and has been withdrawn from
marketing worldwide. The primary end point for PROTECHT was a
composite of symptomatic VTEs and arterial thromboembolic events
during treatment and follow-up.19 In PROTECHT, 3.9% of patients
in the control arm experienced events compared with 2.0% of patients
treated with nadroparin for an NNT of 53 (one-tailed P ⫽ .02). Major
bleeding rates were not different between the arms. In an exploratory
subgroup analysis, thromboembolic event rates were greater in patients who received thromboprophylaxis compared with controls:
8.3% versus 5.9%. In SAVE-ONCO, fewer symptomatic VTE events
occurred in patients who received semuloparin (1.2%) compared
with placebo (3.4%; HR, 0.36; 95% CI, 0.21 to 0.60; P ⬍ .001).18 The
absolute risk difference for VTE events was 2.2% for an NNT of 45.
Major bleeding was similar across arms (HR, 1.05; 95% CI, 0.55 to
1.99).
Two double-blind RCTs of ambulatory patients with metastatic
breast carcinoma (TOPIC-1) or stage III/IV non–small-cell lung carcinoma (TOPIC-2) compared certoparin 3,000 IU subcutaneously
once daily with placebo for 6 months.26 The primary outcome was
symptomatic or asymptomatic VTE. TOPIC-1 randomly assigned
353 patients but was stopped after an interim analysis revealed no
difference between treatment arms. VTE occurred in 4% from both
study arms, resulting in an OR of 1.02 (95% CI, 0.30 to 3.48). TOPIC-2
randomly assigned 547 patients, 4.5% of whom experienced VTE in
the certoparin arm and 8.3% in the placebo arm (OR, 0.52; 95% CI,
0.23 to 1.12). Major bleeding in the certoparin and control arms was
1.7% and 0% in TOPIC-1 and 3.7% and 2.2% in TOPIC-2, respectively, neither of which was statistically significant. A post hoc exploratory analysis demonstrated a reduction in VTE in stage IV lung
carcinoma in the certoparin arm (3.5% v 10.2%; P ⫽ .032).
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Pancreatic cancer. The FRAGEM and PROSPECT-CONKO
004 trials enrolled patients with advanced pancreatic neoplasms.21,25
The FRAGEM trial was a phase IIb RCT of 123 patients with advanced
pancreatic cancer receiving gemcitabine-based chemotherapy comparing thromboprophylaxis with therapeutic doses of dalteparin up to
12 weeks, following a schedule similar to that of the CLOT (Randomized Comparison of Low Molecular–Weight Heparin Versus Oral
Anticoagulant Therapy for the Prevention of Recurrent Venous
Thromboembolism in Patients with Cancer) trial, with no thromboprophylaxis.21 VTE over the course of the study was reduced from
28% to 12%, with a relative risk of 0.42 (95% CI, 0.19 to 0.94; P ⫽
.039). No differences in rates of major bleeding or mortality between
study arms were observed.
The PROSPECT-CONKO 004 trial was presented as an oral
presentation but has not yet been published.25 In this trial, 312 patients
with stage IV pancreatic cancer being treated with gemcitabine-based
chemotherapy were randomly assigned to enoxaparin at half the
therapeutic dose for 3 months or no thromboprophylaxis. VTE
was reduced from 15% to 5%, with a relative risk of 0.35 (95%
CI, 0.16 to 0.75; P ⫽ .007). Again, no significant difference in
rates of major bleeding was reported.
Glioma. The PRODIGE trial included 186 patients with newly
diagnosed grade 3 or 4 glioma and was terminated early.23 Patients
were randomly assigned to dalteparin or placebo for 6 months, and
therapy could continue for an additional 6 months. VTE events occurred in nine patients (9%) in the dalteparin arm compared with 13
patients (15%) in the placebo arm (HR, 0.51; 95% CI, 0.19 to 1.40; P ⫽
.29). Five patients in the dalteparin arm experienced intracranial
bleeding by 12 months compared with one in the control arm (HR,
4.2; 95% CI, 0.48 to 36; P ⫽ .22).
Overall, the Panel concluded that offering all patients with solid
malignancies anticoagulation for thromboprophylaxis in the ambulatory setting is not justified based on the available clinical trial data and
the heterogeneity of this patient population.
Multiple myeloma. Two RCT substudies assessed different
thromboprophylaxis strategies in patients with newly diagnosed multiple myeloma receiving lenalidomide- or thalidomide-based treatment.20,22 Palumbo et al22 stratified patients on the basis of age and
transplantation eligibility and then randomly assigned them to one
of two chemotherapy regimens. Patients who received thalidomidebased regimens were eligible for random assignment to warfarin,
low-dose aspirin, or enoxaparin. Of 659 analyzed patients, serious
thromboembolic events, acute cardiovascular events, or sudden death
during the first 6 months occurred in 6.4% in the aspirin group, 8.2%
in the warfarin group, and 5.0% in the LMWH group. Compared with
LMWH, the absolute differences were 1.3% (95% CI, 3.0% to 5.7%;
P ⫽ .544) with aspirin and 3.2% (95% CI, 1.5% to 7.8%; P ⫽ .183)
with warfarin. Three major bleeding episodes occurred with aspirin
(1.4%) compared with none in the other arms.22 No difference in the
risk of VTE was found when comparing aspirin with LMWH (HR,
1.13; 95% CI, 0.59 to 2.17).
In the other study from the same group, 342 patients with newly
diagnosed multiple myeloma treated with lenalidomide-based chemotherapy were randomly assigned to either prophylactic low-dose
aspirin (100 mg per day) or enoxaparin during induction and consolidation chemotherapy.20 Symptomatic VTE was reported in 2.3% of
patients receiving aspirin and 1.2% receiving LMWH for an absolute
difference of 1.07% (95% CI, ⫺1.69 to 3.83; P ⫽ .452). No major
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bleeding was reported in either arm, and minor bleeding was noted in
one patient receiving enoxaparin.
CLINICAL QUESTION 3
Should patients with cancer undergoing surgery receive perioperative
VTE prophylaxis?
Recommendation 3.1
All patients with malignant disease undergoing major surgical
intervention should be considered for pharmacologic thromboprophylaxis with either UFH or LMWH unless contraindicated because
of active bleeding or high bleeding risk.
Recommendation 3.2
Prophylaxis should be commenced preoperatively.
Recommendation 3.3
Mechanical methods may be added to pharmacologic thromboprophylaxis but should not be used as monotherapy for VTE prevention unless pharmacologic methods are contraindicated because
of active bleeding or high bleeding risk.
Recommendation 3.4
A combined regimen of pharmacologic and mechanical prophylaxis may improve efficacy, especially in the highest-risk patients.
Recommendation 3.5
Pharmacologic thromboprophylaxis for patients undergoing
major surgery for cancer should be continued for at least 7 to 10 days.
Extended prophylaxis with LMWH for up to 4 weeks postoperatively
should be considered for patients undergoing major abdominal or
pelvic surgery for cancer who have high-risk features such as restricted
mobility, obesity, history of VTE, or with additional risk factors as
listed in Table 3. In lower-risk surgical settings, the decision on appropriate duration of thromboprophylaxis should be made on a case-bycase basis considering the individual patient.
Literature Update and Analysis 3
Six meta-analyses27-32 and three RCTs33-35 of perioperative prophylaxis in patients with cancer were identified by the updated systematic review. Three of the meta-analyses28,30,31 and one of the RCTs
considered extended perioperative thromboprophylaxis.33
Primary Prophylaxis
A Cochrane meta-analysis comparing prophylactic LMWH with
UFH in the cancer perioperative setting found little difference in rates
of PE and DVT.32 Major bleeding was also similar with the two
anticoagulants (RR, 0.84; 95% CI, 0.52 to 1.36). A systematic review
limited to patients undergoing surgery for gynecologic cancer compared UFH, LMWH, or sequential compression devices with either
untreated controls or one another.29 A reduction in DVT with UFH
compared with untreated controls was observed (RR, 0.58; 95% CI,
0.35 to 0.95), but there was no difference between UFH and LMWH
(RR, 0.91; 95% CI, 0.38 to 2.17). Bleeding rates were not reported.
The three RCTs that assessed primary perioperative prophylaxis
included patients undergoing abdominal or pelvic surgery. In the
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Sakon et al34 trial, 164 patients with cancer undergoing abdominal
laparotomy were randomly assigned to enoxaparin or intermittent
pneumatic compression (IPC). The incidence of symptomatic VTE
was 1.2% (95% CI, 0.03 to 6.53%) in the enoxaparin group and 19.4%
(95% CI, 7.45 to 37.47%) in the IPC group. Major bleeding was
reported in 4.6% (95% CI, 1.5% to 10.4%) in the enoxaparin group
and 2.6% (95% CI, 0.1% to 13.8%) in the IPC group. The SAVEABDO (Evaluation of AVE5026 as Compared to Enoxaparin for the
Prevention of Venous Thromboembolism in Patients Undergoing
Major Abdominal Surgery)33 and Simonneau et al35 trials compared
two different LMWH regimens. SAVE-ABDO was a randomized,
double-blind, phase III trial of 4,414 patients undergoing major abdominal surgery, of whom 81% underwent surgery for malignant
disease. Patients were randomly assigned to either ultra-LMWH
semuloparin starting before surgery or enoxaparin starting after surgery. The primary outcome of any VTE and all-cause mortality occurred in 5.5% of those receiving enoxaparin and 6.3% receiving
semuloparin (OR, 1.16; 95% CI, 0.84 to 1.59). There were fewer events
of major bleeding with semuloparin (OR, 0.63; 95% CI, 0.46 to 0.87).
In the double-blind Simonneau et al study, patients with colorectal
cancer were randomly assigned to nadroparin or enoxaparin, both
starting before surgery.35 Of 1,288 patients randomly assigned, only
950 (73.8%) were analyzed, with symptomatic and asymptomatic
VTE rates of 15.9% with nadroparin and 12.6% with enoxaparin for a
relative risk of 1.27 (95% CI, 0.93 to 1.74; not significant). Major
bleeding was reported in 11.5% of patients receiving enoxaparin and
7.3% receiving nadroparin (RR, 0.64; 95% CI, 0.45 to 0.91; P ⫽ .012).
These surgical studies were conducted in patients with GI, gynecologic, or urologic malignancies undergoing major cancer surgeries
and examined thromboprophylaxis administered for approximately 7
to 10 days. This duration was established in historical trials of primary
prophylaxis in the surgical setting.36-44 There are no studies assessing
shorter durations or limiting thromboprophylaxis during the hospitalization for lower risk cancer surgery.
Extended Prophylaxis
Three systematic reviews of extended prophylaxis, for 4 weeks
postoperatively with LMWH in mixed cancer and noncancer populations, were reported.28,30,31 The meta-analysis by Bottaro et al28 included three trials involving 1,104 patients, 70.6% of whom had
cancer. A decrease in asymptomatic and symptomatic VTE among
patients with cancer was noted in a subgroup analysis (RR, 0.46; 95%
CI, 0.28 to 0.77). Major bleeding was not significantly different in the
treatment groups overall (RR, 0.83; 95% CI, 0.22 to 3.12), although no
cancer-specific rates were reported. Akl et al31 included three trials or
subgroups of trials representing patients with cancer and reported a
decrease in the risk of asymptomatic DVT with extended LMWH
prophylaxis versus untreated control or placebo (RR, 0.21; 95% CI,
0.05 to 0.94). No significant difference in the risk of major bleeding
was reported (RR, 2.94; 95% CI, 0.12 to 71.85). Rasmussen et al30
included one additional trial in their meta-analysis but did not present
results specifically among patients with cancer undergoing surgery.
The incidence of asymptomatic and symptomatic VTE after major
abdominal or pelvic surgery was 14.3% among controls and 6.1%
among those receiving extended prophylaxis with LMWH (OR, 0.41;
95% CI, 0.26 to 0.63; P ⬍ .001). Although major bleeding events were
not presented separately, all bleeding events in the control and LMWH
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groups were 3.7% (95% CI, 2.4% to 5.5%) and 4.1% (95% CI, 2.7% to
6.0%), respectively (OR, 1.11; 95% CI, 0.62 to 1.97; P ⫽ .73).
The more recent CANBESURE (Cancer, Bemiparin, and Surgery
Evaluation) study randomly assigned 626 patients undergoing abdominal or pelvic cancer surgery to either extended thromboprophylaxis with bemiparin (28 days) or bemiparin (8 days) in a double-blind
fashion.45 The primary outcome of asymptomatic or symptomatic
DVT, nonfatal PE, or all-cause mortality during the double-blind
period occurred in 10.1% of patients receiving bemiparin and 13.3%
of those in the placebo group, and the primary end point was not met
(RR, 0.75; 95% CI; 0.46 to 1.24; P ⫽ .26). Major bleeding was reported
in two patients (0.6%) receiving bemiparin and one (0.3%) in the
placebo arm (not significant). While the study was underway, but
before unblinding, a secondary outcome of major VTE was defined as
asymptomatic proximal or symptomatic proximal DVT, nonfatal PE,
and VTE-related death. At the end of the double-blind period, major
VTE was reported in two (0.8%) and 11 (4.6%) patients, respectively
(RR, 0.18; 95% CI; 0.04 to 0.78; P ⫽ .010).
CLINICAL QUESTION 4
What is the best method for treatment of patients with cancer with
established VTE to prevent recurrence?
Recommendation 4.1
LMWH is preferred over UFH for the initial 5 to 10 days of
anticoagulation for the patient with cancer with newly diagnosed VTE
who does not have severe renal impairment (defined as creatinine
clearance ⬍ 30 mL/min).
Recommendation 4.2
For long-term anticoagulation, LMWH for at least 6 months is
preferred because of improved efficacy over VKAs. VKAs are an acceptable alternative for long-term therapy if LMWH is not available.
Recommendation 4.3
Anticoagulation with LMWH or VKAs beyond the initial 6
months may be considered for select patients with active cancer, such
as those with metastatic disease or those receiving chemotherapy.
Recommendation 4.4
The insertion of a vena cava filter is only indicated for patients
with contraindications to anticoagulant therapy (Table 4). It may be
considered as an adjunct to anticoagulation in patients with progression of thrombosis (recurrent VTE or extension of existing thrombus)
despite optimal therapy with LMWH.
Recommendation 4.5
For patients with primary CNS malignancies, anticoagulation is
recommended for established VTE as described for other patients with
cancer. Careful monitoring is necessary to limit the risk of hemorrhagic complications.
Recommendation 4.6
Use of novel oral anticoagulants for either prevention or treatment of VTE in patients with cancer is not recommended at this time.
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Table 4. Contraindications and Other Considerations to Withhold Therapeutic
Anticoagulant Therapy in Patients With Cancer and VTEⴱ
Contraindication/Consideration
Absolute contraindications†
Active major, serious, or potentially life-threatening bleeding not
reversible with medical or surgical intervention, including but not
limited to any active bleeding in a critical site (ie, intracranial,
pericardial, retroperitoneal, intraocular, intra-articular, intraspinal)
Severe, uncontrolled malignant hypertension
Severe, uncompensated coagulopathy (eg, liver failure)
Severe platelet dysfunction or inherited bleeding disorder
Persistent, severe thrombocytopenia (⬍ 20,000/␮L)
Surgery or invasive procedure, including but not limited to lumbar
puncture, spinal anesthesia, and epidural catheter placement
Relative contraindications‡
Intracranial or spinal lesion at high risk for bleeding
Active peptic or other GI ulceration at high risk of bleeding
Active but non–life-threatening bleeding (eg, trace hematuria)
Intracranial or CNS bleeding within past 4 weeks
Major surgery or serious bleeding within past 2 weeks
Persistent thrombocytopenia (⬍ 50,000/␮L)
Patients for whom anticoagulation is of uncertain benefit
Patient receiving end-of-life/hospice care
Very limited life expectancy with no palliative or symptom reduction
benefit
Asymptomatic thrombosis with concomitant high risk of serious
bleeding
Patient characteristics and values
Preference or refusal
Nonadherence to dosing schedule, follow-up, or monitoring
Abbreviation: VTE, venous thromboembolism.
ⴱ
These criteria are specific for therapeutic doses of anticoagulation and
should not be applied to prophylactic doses of anticoagulation.
†Absolute contraindications are situations in which anticoagulation should
not be administered because the risk of harm associated with bleeding is likely
to exceed the potential benefit from anticoagulation.
‡Relative contraindications are situations in which anticoagulation may be
administered if the risk of recurrent or progressive thrombosis is estimated to
exceed the risk of bleeding.
Recommendation 4.7
Based on consensus, incidental PE and DVT should be treated
in the same manner as symptomatic VTE. Treatment of splanchnic
or visceral vein thrombi diagnosed incidentally should be considered on a case-by-case basis, considering potential benefits and
risks of anticoagulation.
Literature Update and Analysis 4
Three systematic reviews relevant to VTE treatment and secondary prophylaxis were identified.46-48 No new RCTs that met inclusion
criteria were identified.
Systematic Reviews
Data on the relative efficacy and safety of LMWH and UFH for
initial treatment in patients with cancer come from post hoc subgroup
analysis of large RCTs.48 Differences in recurrent thrombosis and
bleeding were not observed. However, a reduction in mortality with
LMWH compared with UFH at 3 months of follow-up was estimated
(RR, 0.71; 95% CI, 0.52 to 0.98). A systematic review and metaanalysis comparing LMWH and VKAs for long-term anticoagulation
was reported by the Cochrane Collaboration.47 The rate of recurrent
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thromboembolism was lower with LMWH (RR, 0.49; 95% CI, 0.34 to
0.70), but the rates of mortality and bleeding were similar.
Romera-Villegas et al46 assessed LMWH dose (full, intermediate,
or prophylactic) compared with VKAs for long-term VTE treatment.
LMWH at full (RR, 0.37; 95% CI, 0.19 to 0.74) or intermediate (RR,
0.52; 95% CI, 0.35 to 0.79) dose was superior to a VKA. No difference
between prophylactic doses of LMWH and VKA was found based on
small numbers of patients. Indirect comparison revealed no differences in major bleeding between the LMWH doses.
Initial and Long-Term Treatment Up to 6 Months
For initial therapy in patients with established VTE without renal
impairment (creatinine clearance ⬎ 30 mL/min), a Cochrane metaanalysis found improved survival with LMWH over UFH in patients
with cancer.48 However, a small RCT in elderly patients with renal
insufficiency (only 6% with cancer) reported higher mortality with
tinzaparin compared with UFH (see Special Populations).49 For treatment up to 6 months, meta-analyses and RCTs validate superiority of
LMWH over VKAs.47,50-52
Data on other anticoagulants for patients with cancer are limited.
Fondaparinux has been used for initial53 and extended therapy for
VTE54 in patients with cancer. The numbers of patients in these
reports were small. Nonetheless, although fondaparinux may be an
alternative for patients with heparin-induced thrombocytopenia, it
does not have a US Food and Drug Administration indication in
this setting.
Treatment Beyond 6 Months
No published studies address optimal anticoagulation beyond
the first 6 months in patients with cancer. However, it is the consensus
of the Panel, based on extrapolation from patients with idiopathic
VTE, that continuing anticoagulation beyond 6 months should be
considered for selected patients because of the persistent high risk of
recurrence in those with active cancer. The decision to continue anticoagulation must be balanced against the risk of bleeding, cost of
therapy, quality of life, life expectancy, and patient preference.
Novel Oral Anticoagulants
Novel anticoagulants that target thrombin (direct thrombin inhibitor dabigatran) or activated factor X (antifactor Xa inhibitors
rivaroxaban, apixaban, and edoxaban) are now approved for selected
indications in VTE prevention and treatment. However, RCTs evaluating these drugs for VTE treatment included few patients with malignant disease: RECOVER (Dabigatran Versus Warfarin in the
Treatment of Acute Venous Thromboembolism) study of dabigatran,
5%55; EINSTEIN trials of rivaroxaban, 6.8% (DVT; Oral Direct Factor
Xa Inhibitor Rivaroxaban in Patients With Acute Symptomatic Deep
Vein Thrombosis), 4.7% (PE; Oral Direct Factor Xa Inhibitor Rivaroxaban in Patients With Acute Symptomatic Pulmonary Embolism),
and 4.7% (Extended Treatment; Once-Daily Oral Direct Factor Xa
Inhibitor Rivaroxaban in the Long-Term Prevention of Recurrent
Symptomatic Venous Thromboembolism in Patients With Symptomatic Deep-Vein Thrombosis or Pulmonary Embolism)56,57; and
AMPLIFY-EXT (Apixaban After Initial Management of PE and VTE
With First-Line Therapy–Extended Treatment) trial of apixaban,
1.8% (2.5 mg) and 1.1% (5 mg).58 Additional concerns with using
these agents in patients with cancer include: unpredictable absorption
and higher risk of GI bleeding in those with mucositis or other GI
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complications, altered metabolism in those with liver or renal impairment, drug interaction with hormonal and chemotherapeutic agents,
inability to measure the anticoagulant activity using standard assays,
and lack of an antidote. In a placebo-controlled pilot study of primary
prophylaxis with apixabain for 3 months in patients with advanced or
metastatic cancer, Levine et al59 reported major bleeding in only 2.2%
of patients. Nonetheless, adequately powered RCTs are needed to
examine the efficacy and safety of these drugs in patients with cancer.
Recurrent VTE
Patients with recurrent VTE despite standard doses of anticoagulant therapy should be assessed for treatment compliance,
heparin-induced thrombocytopenia, or any evidence of mechanical
compression resulting from malignancy. Otherwise, management options include treatment with an alternate anticoagulant regimen, increasing the dose of LMWH, or adding a vena cava filter to LMWH. In
patients for whom standard doses of LMWH fail, higher doses should
be considered and are generally well tolerated in those without an
increased risk of bleeding. In a retrospective study of patients with
cancer and recurrent thrombosis, increasing the LMWH dose by 20%
to 25% was effective in preventing further recurrence.60
Incidental VTE
Incidental findings of PE and/or DVT during routine staging
with computed tomography scans of abdomen and pelvis as well as
splanchnic or visceral vein thrombi are frequently reported. In a recent
large systematic review and meta-analysis of 12 studies including ⬎
10,000 patients, those had a weighted mean prevalence of incidental
PE of 3.1% (95% CI, 2.2 to 4.1%).61 In a retrospective cohort analysis
by Moore et al,62 44% of all thromboembolic events were incidental.
In a cohort study by Singh,63 50% of DVTs and ⬎ 35% of PEs were
incidentally discovered. The pulmonary distribution of incidental emboli is no different from that of symptomatic emboli, with nearly half
occurring in major pulmonary vessels.64,65 Importantly, rates of VTE
recurrence, bleeding, and mortality seem to be similar in patients with
cancer and incidental VTE compared with those with symptomatic VTE.64-68
Vena Cava Filter
The role of inferior vena cava (IVC) filters remains uncertain and
controversial because of the paucity of trials. In an 8-year follow-up
report from the only RCT of permanent IVC filters, the addition of
IVC filters to standard anticoagulation for at least 3 months compared
with anticoagulation alone reduced the risk of PE but increased the
incidence of DVT and had no effect on survival.69 Patients with cancer
constituted 16% and 12% of those with and without filters, respectively. In a small RCT comparing fondaparinux alone for 90 days with
fondaparinux and IVC filter placement, no difference in recurrent
VTE, bleeding, or mortality was found.54 Cohort studies in patients
with cancer suggest much higher rates of recurrent VTE and no survival advantage with filters.70 It remains unclear whether permanent
or retrievable filters are preferable in the cancer setting. It is reasonable
to select a retrievable filter when the contraindication to anticoagulation is expected to be transient. The safety, however, of retrievable
filters has raised serious concerns. In 2010, the US Food and Drug
Administration released a safety alert for optional recovery filters in
response to the high number of adverse events reported.71
© 2013 by American Society of Clinical Oncology
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Intracranial Malignancy
Patients with intracranial tumors are at increased risk for thrombotic complications and intracranial hemorrhage. However, presence
of an intracranial tumor or brain metastasis is not an absolute contraindication to anticoagulation. Limited data support use of antithrombotic therapy in patients with primary or metastatic brain tumors who
develop concurrent venous thrombosis.72-77 A high failure rate has
been reported with IVC filters, without improved overall survival or
reduced intracranial hemorrhage in small retrospective series.74,75,77
Special Populations
Evidence on LMWH and other anticoagulants in special patient
populations comes largely from patients without cancer. Most studies
were retrospective, had small samples, and did not include appropriate control groups. Although increasing age is a risk factor for bleeding, anticoagulant therapy should be offered to elderly patients who
have no contraindications. Caution and close monitoring are necessary in those with renal impairment, cognitive decline, and without
family or nearby support.
The elderly. The IRIS (Innohep in Renal Insufficiency Study)
trial comparing tinzaparin with UFH for initial therapy in patients
age ⱖ 70 years with renal impairment was terminated early because of
an excess number of deaths in the tinzaparin group.49 Poor prognosis
factors, including cancer, were over-represented in the tinzaparin
arm. Because of early termination, the study was underpowered to
detect differences in clinically relevant bleeding and recurrent VTE.
Renal impairment. Bleeding risk is high in patients with renal
impairment and likely even higher in those with concurrent cancer.
Limited data suggest that LMWH can accumulate when therapeutic
doses are administered to patients with creatinine clearance ⬍ 30
mL/min and that the risk of bleeding in these patients is at least
two-fold higher than in patients with normal creatinine clearance.78
Studies indicate that enoxaparin requires dose reduction, but tinzaparin does not.79-81 Data on dalteparin at therapeutic doses in patients
with renal impairment are lacking. Anti-Xa monitoring is recommended if LMWH is used in patients with moderate to severe renal
impairment. If this is not available, UFH and VKAs are safer options
for initial and long-term treatment, respectively.
Obesity. In obese patients, LMWH dosing has not been well
studied. Cohort studies using enoxaparin and dalteparin suggest that
LMWH dose should be based on a patient’s actual body weight.82,83
Bleeding risk does not seem to be higher in obese patients.
CLINICAL QUESTION 5
Should patients with cancer receive anticoagulants in the absence of
established VTE to improve survival?
Recommendation 5.1
Anticoagulants are not recommended to improve survival in
patients with cancer without VTE.
Recommendation 5.2
Patients with cancer should be encouraged to participate in clinical trials designed to evaluate anticoagulant therapy as an adjunct to
standard anticancer therapies.
2200
© 2013 by American Society of Clinical Oncology
Literature Update and Analysis 5
The updated systematic review identified three systematic
reviews84-86 and one RCT.87 All included patients who did not have
any indication for anticoagulation.
The systematic review and meta-analysis from Kuderer et al84
evaluated the impact of anticoagulation on survival. The general comparison of any anticoagulation with no therapy—as well as the more
specific LMWH or warfarin versus no therapy— demonstrated a
lower mortality risk at 1 year with anticoagulation. Bleeding rates were
higher with any anticoagulation (RR, 2.31; 95% CI, 1.93 to 2.76).
Two Cochrane reviews were published on this topic; one evaluated survival with oral anticoagulation and the other with parenteral
agents.85,86 Comparisons of warfarin with no therapy showed no
significant differences in mortality or the incidence of VTE. As expected, warfarin was associated with increased bleeding. In the comparisons of UFH or LMWH versus placebo, a decrease in mortality
was noted at 2 years (RR, 0.92; 95% CI, 0.88 to 0.97). This decrease was
also noted in the small subgroup of patients with small-cell lung
cancer (RR, 0.86; 95% CI, 0.75 to 0.98).
One RCT included patients with advanced lung, hormonerefractory prostate, or pancreatic cancer and life expectancy ⬍ 6
months.87 Patients were randomly assigned to 6 weeks of LMWH or
no treatment. No benefit in overall survival was noted (HR, 0.94; 95%
CI, 0.75 to 1.18). This trend was consistent in the subgroup analysis by
cancer type.
CLINICAL QUESTION 6
What is known about risk prediction and awareness of VTE among
patients with cancer?
Recommendation 6.1
Based on consensus, the Panel recommends that patients with
cancer be assessed for VTE risk at the time of chemotherapy initiation
and periodically thereafter. Individual risk factors, including biomarkers and cancer site, do not reliably identify patients with cancer at high
risk of VTE. In the outpatient setting, risk assessment can be conducted based on a validated risk assessment tool (Table 5).
Recommendation 6.2
Based on consensus, the Panel recommends that oncologists
educate patients regarding VTE, particularly in settings that increase
risk such as major surgery, hospitalization, and while receiving systemic antineoplastic therapy.
Literature Update and Analysis 6
The risk systematic review identified five cohort studies.62,88-91
Two reported development of new risk assessment models,88,89 and
three evaluated existing models.62,90,91 The International Myeloma
Working Group proposed a consensus-based risk assessment algorithm to categorize risk among patients with myeloma; validation is
awaited.92 Several VTE risk assessment tools have been developed and
validated in the perioperative setting, but none has specifically focused
on patients with cancer.93
Multiple cancer-, treatment-, and patient-related risk factors for
VTE relevant to various cancer populations are summarized in Table
3.91,94-96 Although patients with brain, pancreatic, stomach, kidney,
JOURNAL OF CLINICAL ONCOLOGY
VTE Prophylaxis and Treatment: ASCO Guideline Update
Table 5. Predictive Model for Chemotherapy-Associated VTE in the
Ambulatory Setting
Patient Characteristic
Site of cancer
Very high risk (stomach, pancreas, primary
brain tumor)
High risk (lung, lymphoma, gynecologic,
bladder, testicular, renal tumors)
Prechemotherapy platelet count ⱖ 350,000/␮L
Hemoglobin level ⬍ 10 g/dL or use of red-cell
growth factors
Prechemotherapy leukocyte count ⬎ 11,000/␮L
Body mass index ⱖ 35 kg/m2
Calculate total score, adding points for each
criterion in the model
Interpretation:
High risk ⱖ 3 points
Intermediate risk, 1 to 2 points
Low risk, 0 points
Points
2
1
1
1
1
1
NOTE. Data adapted.88
Abbreviation: VTE, venous thromboembolism.
ovarian, or lung cancer are commonly considered at high risk for VTE,
patients with hematologic malignancies are also at elevated risk.97,98
Hospitalization or major surgery can lead to a transient increase in
risk.2,3,27-32,34,35,45,99 Specific therapeutic agents such as thalidomide,22
lenalidomide,20 and cisplatin62,100 can also increase VTE risk. Although a number of biomarkers have been evaluated, neither solitary
risk factors nor individual biomarkers reliably identify high-risk
patients.101-103
A multivariable clinical risk assessment model for VTE was developed and internally validated in a cohort of ambulatory patients
with cancer receiving systemic chemotherapy (Table 5).88 This model
has now been externally validated for predicting risk of VTE by several
investigators.90,91 The balance of benefit and harm with thromboprophylaxis for high-risk patients identified by the model is under study.
Therefore, routine thromboprophylaxis in this setting is not currently recommended.
PATIENT AND CLINICIAN COMMUNICATION
Despite the well-known association of VTE and cancer, patients are
woefully unaware of that risk and of warning signs and symptoms.
Two patient surveys found that fewer than half of patients were aware
of the increased risk of VTE associated with malignancy.105,106 In a
survey of hospitalized patients receiving thromboprophylaxis, responders reported hearing about VTE more frequently from friends,
family, or the media than from health care providers.107 A different
survey indicates that inpatients knew more about VTE than outpatients: 36% versus 15%.106
The need for increased patient education and awareness is clear.
Educated patients are more likely to report symptoms that could lead
to early intervention.107 In addition, aware and educated patients are
more likely to accept efforts such as anticoagulation or early mobility
after surgery. In fact, a qualitative survey of patients with cancer noted
that increased awareness of VTE led to increased acceptance of prowww.jco.org
phylactic LMWH. Many patients reported improved quality of life
secondary to a feeling of safety and reassurance.108
Communicating with patients about the signs, symptoms, and
risk of VTE is crucial. Oncologists, along with other health care professionals on the oncology team, should assure, at minimum, that
patients have a basic recognition of VTE warning signs. Nurses are in
an ideal position to educate patients.109 Resources, including information sheets and symptom checklists, are available to facilitate such
conversations. Respondents to the qualitative survey who were given
educational materials or directed to such (15% of the sample) found
those materials “very useful.”106
Further education can help patients distinguish between symptoms secondary to their underlying disease, treatment, and other
potential causes. Patients may not report new symptoms, unless queried directly, because they mistakenly assume symptoms are manifestations of their cancer or adverse effects of therapy. A good patient
history, along with ongoing communication with the health care
team, can help ensure effective communication as well as facilitate
patient understanding.
HEALTH DISPARITIES
Rates of VTE are higher among African Americans than in the general
population overall.110,111 Rates are lower in the Asian population than
in other ethnicities.111 A nationwide analysis of nearly 500,000 patients
with cancer in Taiwan recently described risk factors and a scoring
system for this population.112 Applicability of these findings to North
American and European patients is unknown.
Although ASCO clinical practice guidelines represent expert recommendations on best practices to provide the highest level of cancer
care, it is important to note that many patients have limited access to
medical care. Racial and ethnic disparities in health care contribute
significantly to this problem in the United States. Minority racial/
ethnic patients with cancer suffer disproportionately from comorbidities, experience more substantial obstacles to receiving care, are more
likely to be uninsured, and are at greater risk of receiving care of poor
quality than other Americans.113-116 Many other patients lack access to
care because of geography or distance from appropriate treatment
facilities. Awareness of these disparities in access to care should be
considered in the context of this clinical practice guideline, and health
care providers should strive to deliver the highest level of cancer care to
these vulnerable populations.
LIMITATIONS
These recommendations are based on data identified by a systematic
review of the literature. Some key questions are, as yet, unanswered.
The potential benefits and harms of thromboprophylaxis in patients
with cancer receiving chemotherapy in the outpatient setting and the
utility of risk assessment require additional research. Future thromboprophylaxis trials in outpatients receiving chemotherapy may benefit from the identification of high-risk groups in whom the balance of
benefits and harms favors prophylaxis.
© 2013 by American Society of Clinical Oncology
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Lyman et al
ADDITIONAL RESOURCES
The Data Supplement, including evidence tables, and clinical tools
and resources can be found at www.asco.org/guidelines/vte. Patient
information is also available there and at www.cancer.net.
AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS
OF INTEREST
Although all authors completed the disclosure declaration, the following
author(s) and/or an author’s immediate family member(s) indicated a
financial or other interest that is relevant to the subject matter under
consideration in this article. Certain relationships marked with a “U” are
those for which no compensation was received; those relationships marked
with a “C” were compensated. For a detailed description of the disclosure
categories, or for more information about ASCO’s conflict of interest policy,
please refer to the Author Disclosure Declaration and the Disclosures of
Potential Conflicts of Interest section in Information for Contributors.
Authors marked with an asterisk (*) are participants in ASCO’s Disclosure
Management System Pilot; their disclosure is not limited to subject matter
under consideration in this article and includes payments to themselves, an
immediate family member (I), and/or their institutions (INST). For
information on the pilot program, or to provide feedback, please visit
coipilot.asco.org.
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Employment or Leadership Position: None Consultant or Advisory
Role: Alok Khorana, Daiichi Sankyo (C), Johnson & Johnson (C), Eisai
(C), sanofi-aventis (C), LEO Pharma (C), Bristol-Myers Squibb (C),
Genentech (C), Eli Lilly (C); Agnes Lee, Bristol-Myers Squibb (C);
Charles W. Francis, Eisai (C); Ajay K. Kakkar, Bayer HealthCare
Pharmaceuticals (C), Boehringer Ingelheim (C), Eisai (C),
GlaxoSmithKline (C), Pfizer (C), sanofi-aventis (C); Howard A.
Liebman, Eisai (C), GlaxoSmithKline (C), Johnson & Johnson (C),
sanofi-aventis (C) Stock Ownership: None Honoraria: Alok Khorana,
Eli Lilly, sanofi-aventis, Daiichi Sankyo, Johnson & Johnson, Eisai, LEO
Pharma, Bristol-Myers Squibb, Genentech; Agnes Lee, Bayer HealthCare
Pharmaceuticals, Boehringer Ingelheim, LEO Pharma, Pfizer,
sanofi-aventis; Juan Ignacio Arcelus, Bayer HealthCare Pharmaceuticals,
Bristol-Myers Squibb, Pfizer, sanofi-aventis Research Funding: *Gary H.
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LEO Pharma; Charles W. Francis, Eisai; Ajay K. Kakkar, Bayer
HealthCare Pharmaceuticals, Boehringer Ingelheim, Eisai,
GlaxoSmithKline, Pfizer, sanofi-aventis Expert Testimony: None Other
Remuneration: None
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Administrative support: Ann Alexis Prestrud
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© 2013 by American Society of Clinical Oncology
JOURNAL OF CLINICAL ONCOLOGY
VTE Prophylaxis and Treatment: ASCO Guideline Update
Acknowledgment
The Update Committee wishes to thank Rose Z. Morrison, Kaitlin Einhaus, Nancy K. Thomasson, Nicholas J. Petrelli MD, Ken Carson, MD,
the Journal of Clinical Oncology editorial board and staff, the Clinical Practice Guidelines Committee for its thoughtful reviews of earlier drafts,
and the American Society of Clinical Oncology Board of Directors.
Appendix
Table A1. Panel Composition
Name
Expertise
ⴱ
Anna Falanga, MD, co-chair
Gary H. Lyman, MD, MPH, co-chairⴱ
Alok A. Khorana, MDⴱ
Nicole M. Kuderer, MDⴱ
Juan Ignacio Arcelus
Edward P. Balaban, DO
Jeffrey M. Clarke, MD
Christopher R. Flowers, MD, MS
Charles W. Francis, MD
Leigh E. Gates, BA, CPHQ
Ajay K. Kakkar, MD, BS, PhD
Nigel S. Key, MB, ChB, FRCP
Agnes Y. Lee, MD, MSc, FRCPC
Mark N. Levine, MD, MSc
Howard A. Liebman, MD
Margaret A. Tempero, MD
Sandra L. Wong, MD
Hematology
Hematology and medical
Hematology and medical
Hematology and medical
Surgery
Hematology and medical
Medical oncology
Hematology and medical
Hematology and medical
Patient representative
Surgery
Hematology and medical
Hematology
Hematology and medical
Hematology and medical
Hematology and medical
Surgical oncology
oncology
oncology
oncology
oncology
oncology
oncology
oncology
oncology
oncology
oncology
ⴱ
Steering Committee member.
www.jco.org
© 2013 by American Society of Clinical Oncology